Provider Demographics
NPI:1942517099
Name:PARK, SANG JU (RN)
Entity Type:Individual
Prefix:MRS
First Name:SANG
Middle Name:JU
Last Name:PARK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USAG-J UNIT # 45013
Mailing Address - Street 2:BOX 2919
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96338-5013
Mailing Address - Country:US
Mailing Address - Phone:315-263-8643
Mailing Address - Fax:315-263-5670
Practice Address - Street 1:USAG-J UNIT # 45013
Practice Address - Street 2:BOX 2919
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96338-5013
Practice Address - Country:US
Practice Address - Phone:315-263-8643
Practice Address - Fax:315-263-5670
Is Sole Proprietor?:No
Enumeration Date:2010-09-10
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA601067163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management